Issues in the identification and long-term management of Munchausen by Proxy Syndrome within a clinical infant service

Munchausen by Proxy Syndrome is a version of Munchausen's Syndrome whereby a parent, usually the mother, simulates or fabricates disease in one or more of her children in order to seek medical attention. Because this disorder is usually identified in pediatric settings, current literature focuses on identification of the syndrome, with little discussion of treatment issues or management strategies other than confrontation of the parent and removal of the child from the home. With the increased availability of infant mental health services, infant clinicians are likely to be called on to evaluate and treat cases of this disorder. This paper reviews the Munchausen by Proxy literature for infant clinicians and describes the identification and long-term management of one Munchausen by Proxy case within the context of an infant home-visiting service. Pertinent issues that emerged included the difficulties inherent in documenting the mother's pathological behavior, the clinical tension between preventing flight from treatment but limiting harmful behavior, the need for a long-term collaborative relationship with a designated pediatrician, and the importance of further education of protective service workers about this syndrome.     

'More in sickness than in health': a case study of Munchausen by Proxy in the elderly

The case of a 69-year-old male with features of Munchausen's Syndrome by Proxy is described. The identified patient was referred to 25 different medical teams, over a four-year period, through the insistence of his 55-year-old female companion, an ex-nurse. Significant factors relating to the diagnosis of patients with Munchausen by Proxy are discussed, and comparisons made between the syndrome as originally described in children and those features presenting later in life. Munchausen by Proxy involving the elderly, may also involve abuse. The authors wish to draw attention to some of the systemic issues involved in such a process, and discuss possible interventions. Attention is also drawn to the difficulties in management of this particular case, and the possible widespread prevalence of less florid and therefore, unrecognized cases in the elderly.     

Munchausen syndrome by proxy: Clinical review and legal issues

Well-established policies and procedures govern the identification, management, and treatment of most variations of child abuse. For many therapists, such cases have become “routine”. Munchausen syndrome by proxy is an under-recognized form of child abuse in which a parent feigns or creates illness in a child specifically to have the child subjected to unnecessary diagnostic tests and treatments by medical practitioners. Variations range from false reports of fevers or allergies, to life-threatening abuse, such as surreptitious poisonings or injections with toxic substances. This article reports a case example of Munchausen syndrome by proxy, provides a review of historical, diagnostic and management issues, and discusses legal issues relevant to detection of the perpetrator and protection of the child victim.     

Examiner Errors on the WAIS-R: A Source of Concern

Munchausen syndrome (MS) is characterized by patients' chronic and relentless pursuit of medical treatment for combinations of symptoms of consciously self-inflicted injury and falsely reported symptomatology. MS patients are adults, as are perpetrators of Munchausen syndrome by proxy (MSBP). MSBP is an unusual form of child abuse in which a parent, usually the mother, brings a child for medical attention with symptoms falsified or directly induced by the mother. Most reports of MSBP have been of a few cases appearing in medical and pediatric literature. Motivation in both disorders is unclear, and diagnosis and treatment present difficult problems that require more research.     

Interparental conflict and adolescent emotional security across family structures

This study investigated whether interparental conflict was differentially related to forms of emotional security (i.e., family, interparental, parent–child) and whether forms of emotional security were differentially associated with mental health problems for adolescents in married versus divorced/separated families. Participants were 1032 adolescents (ages 10–15; 51% male, 49% female; 82% non-Hispanic White, 9% Black/African American, 5% Hispanic, 2% Asian or Pacific Islander, 2% Native American) recruited from a public school in a middle-class suburb of a United States metropolitan area. We used multiple group multivariate path analysis to assess (1) associations between interparental conflict and multiple measures of emotional insecurity (i.e., family, interparental, and parent–child), (2) associations between measures of emotional insecurity and internalizing and externalizing problems, and (3) moderation effects of parent–child relationships. The patterns of association were similar across family structures. A high-quality parent–child relationship did not mitigate the harmful effects of interparental conflict on emotional insecurity or mental health problems. Findings suggest that regardless of family structure, emotional security across multiple family systems may be a critical target for intervention to prevent youth mental health problems, in addition to interventions that reduce conflict and improve parent–child relationships.     

Covert Video Surveillance of Parents Suspected of Child Abuse: The British Experience and Alternative Approaches

One million cases of child maltreatment and twelve hundred child deaths due to abuse and neglect occur per year. But since many cases of abuse and neglect remain either unreported or unsubstantiated due to insufficient evidence, the number of children who are abused, neglected, and killed at the hands of family caregivers is probably higher. One approach to combat child abuse in the U.K. has been the employment of hospital-based covert video surveillance (CVS) to monitor parents suspected of Munchausen Syndrome by Proxy (MSBP). The use of CVS, however, raises concerns about voluntary informed consent, research on human subjects, privacy, and the appropriateness of healthcare providers to conduct CVS. More broadly, the use of CVS raises concerns about the ethical life of healthcare institutions and their moral obligations to the families and communities they serve. The U.K. protocol for CVS is examined in light of these concerns. Three alternative CVS protocols and two procedures for selecting a protocol are then proposed for use in the U.S. The paper concludes that any CVS protocol selected for use by hospitals ought to be selected by means of open and democratic processes that permit community input and, subsequently, the possibility of a consensus on the moral status and scope of CVS.     

Triadic coordination: an observational method for examining whether children are "caught in the middle" of interparental discord.

Triadic coordination refers to how a parent coordinates his or her contributions with the spouse's bids toward their child. This construct provides a basis for studying specifically triadic family interaction processes. In particular, it offers a new approach for examining whether children are "caught in the middle" of marital discord. We conducted an initial, small-scale study of mother-father-child interactions in a structured task in order to pursue the methodological goal of developing an observational procedure for measuring triadic coordination processes. The results suggest that the approach has considerable promise for making a contribution to future research on marital discord and child functioning. We found that processes of triadic coordination can be assessed reliably. Other findings included an interesting pattern of results, which merits further investigation in future studies, concerning relations between whether and how a parent disagreed with or opposed the spouse's bids toward their child, on the one hand, and other measures of family functioning and measures of child functioning, on the other hand.     

Communication and Understanding in Parent–Adolescent Relationships

This research examined communication and parent–adolescent understanding, including understanding about family conflicts, adolescent self‐concepts, and immediate thoughts (or “empathic accuracy”). Fifty parent–adolescent triads completed questionnaires, held a discussion, and reported on immediate thoughts during the discussion using video‐assisted recall methods. Alternative measures of understanding produced distinct results. Parental understanding of the child's self‐concept was associated with frequent and open communication, high parent–child relationship satisfaction, and a strong child self‐concept. Parental understanding of conflict perceptions was associated with high conformity and low relationship satisfaction. Parental understanding of the immediate thoughts of children was quite low overall and was not consistently related to communication, relationship satisfaction, or child self‐concept. The results suggest that alternative measures of understanding reflect different family processes.     

Self-efficacy,parent–child relationships,and academic performance: a comparison of European American and Asian American college students

Parent–child relationships play an important role in successful academic outcomes. Previous research suggests that the association between parent–child relationships and offspring’s academic achievement may be mediated by offspring’s self-efficacy levels, although these relationships are not fully understood. Furthermore, the association between family support and academic outcomes is well-documented among European Americans, but not across cultures. Therefore, the present study examined how parent–child relationship quality relates to young adults’ academic achievement and self-efficacy among European Americans and Asian Americans. Participants were 258 undergraduate students (85 male, 173 female) who completed a survey. Overall, both parent–child relationships and self-efficacy were significantly associated with the offspring’s academic performance, and self-efficacy mediated the relationship between parent–child relationships and school outcomes. Ethnicity moderated these relationships: among European American students, quality of parent–child relationships was not associated with self-efficacy level whereas for Asian Americans, parent–child relationships were associated with self-efficacy. These findings suggest that European American college students’ self-efficacy levels are less dependent on parent–child relationship quality, but for Asian Americans college students it may be important for educators to facilitate communication and family support so students may continue to use family as a resource for self-efficacy levels.     

Behavior Problems in Young Children With or At Risk for Developmental Delay

We examined the prevalence of behavior problems and their relationship to child, parent, and family factors in 76 children with or at risk for developmental delay. Parents reported that 42% of the children had behavior problems. Child Behavior Checklist (CBC) scores revealed that 25% of the sample scored above the borderline cutoff. Although the total, externalizing, and internalizing mean CBC scores did not differ from the normative group (same-aged peers without developmental delay), each of the syndrome subscales was significantly higher in the study group. The Reiss Scales for Children's Dual Diagnosis revealed that, as compared to older children (4 years) with developmental delay, the study sample scored significantly lower on the total score and 8 of the 10 subscales. Increased CBC total scores were significantly related to dependency and management of the child, birth weight, gestational length, paternal illness, maternal depression, perceived personal burden of care, maternal escape-avoidance coping strategy, family disharmony, and financial stress. CBC total scores were significantly negatively correlated with being of a multiple birth, paternal education, maternal employment, two-parent family, family social support, and family income. Multiple regression analyses revealed that an empirically-derived combination of child, parent, and family variables accounted for 31% of the variance in CBC total scores. Our findings suggest that 2-year old children with or at-risk for developmental delay may already be showing signs of increased risk of behavior problems relative to peers without developmental delay. We identified several child, parent, and family variables that may help to pinpoint children at increased riskxs for psychopathology.     

Generalization Across Instructional Settings by Autistic Children

Although parent training generally has been successful, sufficient data exist to indicate that treatment outcome is not always positive. Several investigators have suggested that problems in the family system may be responsible for the failures, which occur. The present paper reviews the relationship between three family problem variables (parental maladjustment, marital difficulties, and dysfunctional extra familial interactions) and child behavior problems and their treatment. The available data suggest that there is a positive relationship between child behavior problems and problems in each of the three types of family variables. Furthermore, although less conclusive, some data suggest that the outcome of parent training is affected adversely by poor parental personal, marital, and extra-familial adjustment. Assessment of generalization form parent training to family problems has yielded mixed results; generalization has occurred primarily to parental personal adjustment. Finally, comparisons of parent training alone to parent training plus treatment of family problems have not been undertaken, Areas for future investigation are discussed.     

Factors of parricide: Allowance of the use of battered child syndrome as a defense

Children who kill a parent may be mentally ill or dangerously antisocial, but most often they are severely abused. However, most abused children do not resort to killing a parent. Children who do commit murder do so out of desperation when family members and friends have failed to help them. This article discusses issues surrounding allowance of the defense of battered child syndrome as a justification for parricide. An argument will be made for the expansion of the self-defense claim to include battered child syndrome.     

Building a composite factorial score for the assessment of quality of parent–child relationships in adolescence

The quality of parent–child relationships has important implications for adolescent development and well-being. However, whereas numerous measures of specific dimensions contributing to quality of parent–child relationships are available, scales that provide a global assessment of this content are scarce. Consequently, the assessment of quality of parent–child relationships poses a challenge to the researcher, especially when the need exists to consider its main aspects but long instruments can not be used due to diverse circumstances. This paper presents a composite factorial score on quality of parent–child relationships developed from four short measures of affection, communication, parental knowledge and family satisfaction that can contribute to solving some of those difficulties. This composite score can be a useful tool to assess quality of parent–child relationships, especially for studies devoted to the study of the relationships between experiences within the family and the adolescent's well-being.     

The single parent: Power and the integrity of parenting

I have explored some issues of power and the balance of power in the situation of the single parent and the family. The single parent may need the support of a holding environment to achieve psychological integration as exemplified by my treatment with Ms. B. Without a cooperative mate and with societal prejudice, the psychotherapeutic situation may be the only nurturing environment. The therapist empowers the single parent by providing a supportive, nurturing environment. Parenting is receiving bad press in this decade. More examples of child abuse and the extreme of homicide come to public attention. Children do have power and society needs to support a constructive use of child as well as parental power. At this stage in societal/cultural development the legal system is unfortunately more available to punish than provide lines of protection or guidance to parent or child. The psychoanalytic literature hasn't been kind or supportive to the parent. We must keep in mind that the psychotherapist's lot is simpler, less stressful, and more protected from real life stresses than that of the single parent. I suggest a model of parenting with the establishment of ongoing dialogue between parent and child in which each is receptive to the other. While it is the parental task to set limits and teach about the real world, the goal is to establish an exchange in which parent and child are both teacher and student. This creative relationship produces growth and builds esteem for parent and child alike.     

Parental Alienation Syndrome and the Transsexual Parent

ABSTRACT

Transsexual persons are frequently married and are parents prior to the decision for gender transition. Divorce and issues of child custody or child access follow. This typically volatile area is made the more incendiary when one parent is transgendered. Parental Alienation Syndrome is an unique alliance between one parent and child of denigration and hostility to the other parent. When the transgendered parent is the target, Courts may collaborate in destruction of the transsexual parent-child relationship.     

The Association Between Reflective Functioning and Parent–Child Relationship Quality

Research consistently links adult and infant attachment styles, yet the means by which attachment is transmitted is relatively elusive. Recently, attention has been directed to the psychological underpinnings of caregiver sensitivity—originally thought to be the mechanism of transmission—as indicated by caregivers’ ability to keep in mind children’s mental states when interpreting children’s behavior, or reflective functioning. Unfortunately for researchers, extant measures of reflective functioning are time-consuming and require extensive observation and coding. A self-report measure could help facilitate the study and assessment of reflective functioning in research and clinical settings. This study investigated the relationship between parental reflective functioning and multiple aspects of the parent–child relationship, by using a new, self-report measure of reflective functioning. Participants were 79 caregivers (M _age = 31.8 years) who completed self-report measures assessing reflective functioning, parent–child relationship characteristics, perceived rejection in early relationships, attachment anxiety and avoidance in current close relationships, depression, and substance use. The results indicated that reflective functioning is a strong predictor of parent–child relationship quality (i.e., parental involvement, communication, parent satisfaction, limit setting, and parental support), independent of other potential indicators. Findings support parental reflective functioning as a contributor to the quality of parent–child relationship and suggest that a parent’s capacity to reflect on the mental states of his or her child in parent–child interactions may provide a key target for interventions that aim to improve parent–child relationships.     

The Role of BIS Sensitivity in the Relationship Between Family Enmeshment and Child Anxiety

Previous work has demonstrated that three overarching vulnerabilities–genetic, environmental, and temperamental–contribute to the development of child anxiety. The purpose of our study was to assess: (a) the relationship between an environmental vulnerability, family enmeshment, and child anxiety; (b) whether parental anxiety accounts for this relationship; and (c) whether this relationship is mediated by levels of child Behavioral Inhibition System sensitivity, a highly persistent temperamental variable demonstrating positive associations with child anxiety. Our study included 38 Canadian parent–child dyads from an urban area, of which 33 children were Caucasian and 18 were girls. Children were aged 9 or 11 years (M = 10.21, SD = 1.07). Children completed measures of anxiety and sensitivity towards threat and parents completed measures of family enmeshment. The results supported a significant positive relationship between family enmeshment and child anxiety; parental anxiety did not account for this relationship; and the relationship was partially mediated by Behavioral Inhibition System sensitivity. Specifically, when the effect of Behavioral Inhibition System sensitivity was controlled for, the association between family enmeshment and child anxiety became non-significant. The results suggest that family enmeshment is associated with levels of child anxiety largely through the function of children’s sensitivity to threat. Enmeshed families may increase children’s susceptibility to anxiety through their effect on child temperament, specifically sensitivity to threat.     

Electrical Brain Activity,Family Functioning,and Parent–Adolescent Conflict Communication

As family conflict tends to escalate during the adolescent years, the subsequent effects of adolescence on parent–child dynamics are systemically experienced, both intra- and inter-personally. As such, widening the scope of literature targeted towards better understanding the parent–adolescent conflict relationship is merited. To offer a more gestalt view of parent–adolescent conflict processes, the present study takes a biopsychosocial view of the mother–father–adolescent relationship by considering electrical brain activity using electroencephalography technology. Specifically, electrical brain activity was recorded during two problem-solving family discussions between a mother, father, and adolescent child. Data is analyzed from a pilot study of 11 triads, for a total of 33 participants, examining the statistical relationships between brain waves and self-reported measures of family functioning and distress. Findings suggest that hemispheric lateralization occurs during parent–adolescent problem-solving discussions thus reminding therapists of the importance in using a biopsychosocial lens when assisting families.